Preview: Obama's Health Care Speech

Looking ahead to the speech, I think there are four key pillars of any health care plan: guaranteed issue, community rating, an individual mandate, and a subsidy. Obama has so far avoided talking about this too specifically, because he's got to navigate this bill through a very narrow political space. On the one hand, the bill can't cost too much, because the American people have sticker shock from the stimulus, the projected deficit is huge and keeps getting bigger, and there are no politically acceptable ways to pay for a huge program. On the other hand, if you have an individual mandate without generous subsidies, you have a bill that any halfway competent Republican could demagogue with one tongue tied behind his back.

I listened to the Republican talking points on the drive over, and here are the key ones:

You're adding a government bureaucracy on top of a health care bureaucracy, which is stupid

Obama's paying for this by cutting Medicare

Medicare is already going broke, so how are we going to pay for the new benefits?

Most people's health insurance works just fine, and it doesn't make sense to destroy the system to help the few who need it

Medical malpractice reform now!

Editorializing aside, these have the advantage of being mostly true, and fairly reasonable-sounding. Luckily for Obama, the skill of the Republican delivery ranged between "Fourth grade Christmas pageant" and "Assistant deacon at the 6 am mass".

Bob Dole had the best comment I heard on CSPAN: "If you get the votes, you can force the American public to swallow just about anything. But you can't make them keep it down." Earlier today, I was speaking with some pretty sharp political analysts, and I asked them why Social Security reform didn't pass? It was a legislative priority that Republican legislators and policy wonks strongly believed in, and had been readying the ground for in the decades since the Greenspan commission. But they couldn't do it.

At the end of the day, I was told, they couldn't get it out of committee because Republicans weren't willing to do this alone. Social Security reform commanded a majority among Republicans, but it was unpopular with independents, and Democrats hated it. They weren't willing to do it with no Democratic votes. They needed political cover, and they didn't get it.

Is this as risky as social security reform? Maybe, if you attach Medicare cuts to it--Democrats may hate Medicare Advantage, but the seniors who use it are presumably pretty attached. I'm struggling to think of a single instance in which we have succeeded in taking any significant service away from even a relatively small group of seniors. Maybe even without the Medicare cuts. Once you get specific, the sob stories are going to come out: the family of six who can't afford the family policy they'll be forced to buy, the widow who just loves her Medicare Advantage, etc. Yes, there will be sob stories on the other side. But people are loss averse. When faced with certain loss over a possible loss/possible gain, they tend to choose the certain loss. That's why scare ads work. Plus the uninsured are less likely to vote than the population as a whole, and in the case of immigrants, they can't.

So I think Democrats are left with two questions:

How much popularity will the bill lose? I think it loses some, because vague things tend to poll better than specific things. Vague things are a blank slate upon which you can project your wishes. Specific things have actual drawbacks. But other, wiser commentators disagree with me here; only time will tell.

Are Democrats willing to put over an unpopular bill with no political cover? The latest poll shows Obama's approval on health care at 42-52. Say it just stays where it is--are they going to muscle it through on a straight party line vote? The really marginal blue dogs are probably toast anyway, but they don't seem to see it that way. But what about the others? A lot of people are pushing the line that Democrats need this because it will boost Obama's popularity, and through it, their own. This rather assumes that ramming through a massive and unpopular bill will improve Obama's popularity. Would Republicans really have done better in 2006 if they had manned up and passed a bill without Democratic support? That's what Democrats need to decide--and if the answer is no, they need to ask themselves whether they're willing to sacrifice their careers on the altar of health care reform.

Judging from the excerpts that have been released, Obama's not going to change this much. If his speech moves the dial on the popularity of health care reform, he'll give them new backbone. But the excerpts are vague and don't say anything we haven't heard a lot of times before. Also, he's competing with several hundred cable channels, and So You Think You Can Dance--the ratings of his recent speeches haven't exactly been stellar. I think it's pretty iffy as to whether this is actually going to galvanize the American public to a whole new committment to health care.